Harmonising dietary datasets for global surveillance: methods and findings from the Global Dietary Database.

OBJECTIVE: The Global Dietary Database (GDD) expanded its previous methods to harmonise and publicly disseminate individual-level dietary data from nutrition surveys worldwide. DESIGN: Analysis of cross-sectional data. SETTING: Global. PARTICIPANTS: General population. METHODS: Comprehensive methods to streamline the harmonisation of primary, individual-level 24-h recall and food record data worldwide were developed. To standardise the varying food descriptions, FoodEx2 was used, a highly detailed food classification and description system developed and adapted for international use by European Food Safety Authority (EFSA). Standardised processes were developed to: identify eligible surveys; contact data owners; screen surveys for inclusion; harmonise data structure, variable definition and unit and food characterisation; perform data checks and publicly disseminate the harmonised datasets. The GDD joined forces with FAO and EFSA, given the shared goal of harmonising individual-level dietary data worldwide. RESULTS: Of 1500 dietary surveys identified, 600 met the eligibility criteria, and 156 were prioritised and contacted; fifty-five surveys were included for harmonisation and, ultimately, fifty two were harmonised. The included surveys were primarily nationally representative (59 %); included high- (39 %), upper-middle (21 %), lower-middle (27 %) and low- (13 %) income countries; usually collected multiple recalls/ records (64 %) and largely captured both sexes, all ages and both rural and urban areas. Surveys from low- and lower-middle v. high- and upper-middle income countries reported fewer nutrients (median 17 v. 30) and rarely included nutrients relevant to diet-related chronic diseases, such as n-3 fatty acids and Na. CONCLUSIONS: Diverse 24-h recalls/records can be harmonised to provide highly granular, standardised data, supporting nutrition programming, research and capacity development worldwide.

Sugar-sweetened beverage intakes among adults between 1990 and 2018 in 185 countries.

Sugar-sweetened beverages (SSBs) are associated with cardiometabolic diseases and social inequities. For most nations, recent estimates and trends of intake are not available; nor variation by education or urbanicity. We investigated SSB intakes among adults between 1990 and 2018 in 185 countries, stratified subnationally by age, sex, education, and rural/urban residence, using data from the Global Dietary Database. In 2018, mean global SSB intake was 2.7 (8 oz = 248 grams) servings/week (95% UI 2.5-2.9) (range: 0.7 (0.5-1.1) in South Asia to 7.8 (7.1-8.6) in Latin America/Caribbean). Intakes were higher in male vs. female, younger vs. older, more vs. less educated, and urban vs. rural adults. Variations by education and urbanicity were largest in Sub-Saharan Africa. Between 1990 and 2018, SSB intakes increased by +0.37 (+0.29, +0.47), with the largest increase in Sub-Saharan Africa. These findings inform intervention, surveillance, and policy actions worldwide, highlighting the growing problem of SSBs for public health in Sub-Saharan Africa.

Development and Validation of the US Diabetes, Obesity, Cardiovascular Disease Microsimulation (DOC-M) Model: Health Disparity and Economic Impact Model.

BACKGROUND: Few simulation models have incorporated the interplay of diabetes, obesity, and cardiovascular disease (CVD); their upstream lifestyle and biological risk factors; and their downstream effects on health disparities and economic consequences. METHODS: We developed and validated a US Diabetes, Obesity, Cardiovascular Disease Microsimulation (DOC-M) model that incorporates demographic, clinical, and lifestyle risk factors to jointly predict overall and racial-ethnic groups-specific obesity, diabetes, CVD, and cause-specific mortality for the US adult population aged 40 to 79 y at baseline. An individualized health care cost prediction model was further developed and integrated. This model incorporates nationally representative data on baseline demographics, lifestyle, health, and cause-specific mortality; dynamic changes in modifiable risk factors over time; and parameter uncertainty using probabilistic distributions. Validation analyses included assessment of 1) population-level risk calibration and 2) individual-level risk discrimination. To illustrate the application of the DOC-M model, we evaluated the long-term cost-effectiveness of a national produce prescription program. RESULTS: Comparing the 15-y model-predicted population risk of primary outcomes among the 2001-2002 National Health and Nutrition Examination Survey (NHANES) cohort with the observed prevalence from age-matched cross-sectional 2003-2016 NHANES cohorts, calibration performance was strong based on observed-to-expected ratio and calibration plot analysis. In most cases, Brier scores fell below 0.0004, indicating a low overall prediction error. Using the Multi-Ethnic Study of Atherosclerosis cohorts, the c-statistics for assessing individual-level risk discrimination were 0.85 to 0.88 for diabetes, 0.93 to 0.95 for obesity, 0.74 to 0.76 for CVD history, and 0.78 to 0.81 for all-cause mortality, both overall and in three racial-ethnic groups. Open-source code for the model was posted at https://github.com/food-price/DOC-M-Model-Development-and-Validation. CONCLUSIONS: The validated DOC-M model can be used to examine health, equity, and the economic impact of health policies and interventions on behavioral and clinical risk factors for obesity, diabetes, and CVD. HIGHLIGHTS: We developed a novel microsimula'tion model for obesity, diabetes, and CVD, which intersect together and - critically for prevention and treatment interventions - share common lifestyle, biologic, and demographic risk factors.Validation analyses, including assessment of (1) population-level risk calibration and (2) individual-level risk discrimination, showed strong performance across the overall population and three major racial-ethnic groups for 6 outcomes (obesity, diabetes, CVD, and all-cause mortality, CVD- and DM-cause mortality)This paper provides a thorough explanation and documentation of the development and validation process of a novel microsimulation model, along with the open-source code (https://github.com/food-price/ DOCM_validation) for public use, to serve as a guide for future simulation model assessments, validation, and implementation.

Children's and adolescents' rising animal-source food intakes in 1990-2018 were impacted by age, region, parental education and urbanicity.

Animal-source foods (ASF) provide nutrition for children and adolescents' physical and cognitive development. Here, we use data from the Global Dietary Database and Bayesian hierarchical models to quantify global, regional and national ASF intakes between 1990 and 2018 by age group across 185 countries, representing 93% of the world's child population. Mean ASF intake was 1.9 servings per day, representing 16% of children consuming at least three daily servings. Intake was similar between boys and girls, but higher among urban children with educated parents. Consumption varied by age from 0.6 at <1 year to 2.5 servings per day at 15-19 years. Between 1990 and 2018, mean ASF intake increased by 0.5 servings per week, with increases in all regions except sub-Saharan Africa. In 2018, total ASF consumption was highest in Russia, Brazil, Mexico and Turkey, and lowest in Uganda, India, Kenya and Bangladesh. These findings can inform policy to address malnutrition through targeted ASF consumption programmes.

Incident type 2 diabetes attributable to suboptimal diet in 184 countries.

The global burden of diet-attributable type 2 diabetes (T2D) is not well established. This risk assessment model estimated T2D incidence among adults attributable to direct and body weight-mediated effects of 11 dietary factors in 184 countries in 1990 and 2018. In 2018, suboptimal intake of these dietary factors was estimated to be attributable to 14.1 million (95% uncertainty interval (UI), 13.8-14.4 million) incident T2D cases, representing 70.3% (68.8-71.8%) of new cases globally. Largest T2D burdens were attributable to insufficient whole-grain intake (26.1% (25.0-27.1%)), excess refined rice and wheat intake (24.6% (22.3-27.2%)) and excess processed meat intake (20.3% (18.3-23.5%)). Across regions, highest proportional burdens were in central and eastern Europe and central Asia (85.6% (83.4-87.7%)) and Latin America and the Caribbean (81.8% (80.1-83.4%)); and lowest proportional burdens were in South Asia (55.4% (52.1-60.7%)). Proportions of diet-attributable T2D were generally larger in men than in women and were inversely correlated with age. Diet-attributable T2D was generally larger among urban versus rural residents and higher versus lower educated individuals, except in high-income countries, central and eastern Europe and central Asia, where burdens were larger in rural residents and in lower educated individuals. Compared with 1990, global diet-attributable T2D increased by 2.6 absolute percentage points (8.6 million more cases) in 2018, with variation in these trends by world region and dietary factor. These findings inform nutritional priorities and clinical and public health planning to improve dietary quality and reduce T2D globally.

WITHDRAWN: Prevalence and factors associated with smoking in a nationally representative sample of Greek adults: The Hellenic National Nutrition and Health Survey (HNNHS).

The Publisher regrets that this article is an accidental duplication of an article that has already been published, https://doi.org/10.1016/j.hjc.2022.05.005. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal

WITHDRAWN: Prevalence and factors associated with smoking in a nationally representative sample of Greek adults: The Hellenic National Nutrition and Health Survey (HNNHS).

The Publisher regrets that this article is an accidental duplication of an article that has already been published, https://doi.org/10.1016/j.hjc.2022.05.005. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal

Implementing federal food service guidelines in federal and private worksite cafeterias in the United States leads to improved health outcomes and is cost saving.

Poor diet increases cardiometabolic disease risk, yet the impact of food service guidelines on employee health and its cost effectiveness is poorly understood. Federal food service guidelines (FFSG) aim to provide United States (U.S.) government employees with healthier food options. Using microsimulation modeling, we estimated changes in the incidence of cardiometabolic disease, related mortality, and the cost effectiveness of implementing FFSG in nationally representative model populations of government and private company employees across 5 years and lifetime. We based estimates on changes in workplace intake of six FFSG dietary targets and showed lifetime reductions of heart attacks (- 107/million), strokes (- 30/million), diabetes (- 134/million), ischemic heart disease deaths (- 56/million), and stroke deaths (- 8/million). FFSG is cost saving overall, with total savings in discounted healthcare costs from $4,611,026 (5 years) to $539,809,707 (lifetime) $U.S. This study demonstrates that FFSG improves health outcomes and is cost saving.

Global, regional, and national consumption of animal-source foods between 1990 and 2018: findings from the Global Dietary Database.

BACKGROUND: Diet is a major modifiable risk factor for human health and overall consumption patterns affect planetary health. We aimed to quantify global, regional, and national consumption levels of animal-source foods (ASF) to inform intervention, surveillance, and policy priorities. METHODS: Individual-level dietary surveys across 185 countries conducted between 1990 and 2018 were identified, obtained, standardised, and assessed among children and adults, jointly stratified by age, sex, education level, and rural versus urban residence. We included 499 discrete surveys (91·2% nationally or subnationally representative) with data for ASF (unprocessed red meat, processed meat, eggs, seafood, milk, cheese, and yoghurt), comprising 3·8 million individuals from 134 countries representing 95·2% of the world population in 2018. We used Bayesian hierarchical models to account for differences in survey methods and representativeness, time trends, and input data and modelling uncertainty, with five-fold cross-validation. FINDINGS: In 2018, mean global intake per person of unprocessed red meat was 51 g/day (95% uncertainty interval [UI] 48-54; region-specific range 7-114 g/day); 17 countries (23·9% of the world's population) had mean intakes of at least one serving (100 g) per day. Global mean intake of processed meat was 17 g/day (95% UI 15-21 g/day; region-specific range 3-54 g/day); seafood, 28 g/day (27-30 g/day; 12-44 g/day); eggs, 21 g/day (18-24 g/day; 6-35 g/day); milk 88 g/day (84-93 g/day; 45-185 g/day); cheese, 8 g/day (8-10 g/day; 1-34 g/day); and yoghurt, 20 g/day (17-23 g/day; 7-84 g/day). Mean national intakes were at least one serving per day for processed meat (≥50 g/day) in countries representing 6·9% of the global population; for cheese (≥42 g/day) in 2·3%; for eggs (≥55 g/day) in 0·7%; for milk (≥245 g/day) in 0·3%; for seafood (≥100 g/day) in 0·8%; and for yoghurt (≥245 g/day) in less than 0·1%. Among the 25 most populous countries in 2018, total ASF intake was highest in Russia (5·8 servings per day), Germany (3·8 servings per day), and the UK (3·7 servings per day), and lowest in Tanzania (0·9 servings per day) and India (0·7 servings per day). Global and regional intakes of ASF were generally similar by sex. Compared with children, adults generally consumed more unprocessed red meat, seafood and cheese, and less milk; energy-adjusted intakes of other ASF were more similar. Globally, ASF intakes (servings per week) were higher among more-educated versus less-educated adults, with greatest global differences for milk (0·79), eggs (0·47), unprocessed red meat (0·42), cheese (0·28), seafood (0·28), yoghurt (0·22), and processed meat (0·21). This was also true for urban compared to rural areas, with largest global differences (servings per week) for unprocessed red meat (0·47), milk (0·38), and eggs (0·20). Between 1990 and 2018, global intakes (servings per week) increased for unprocessed red meat (1·20), eggs (1·18), milk (0·63), processed meat (0·50), seafood (0·44), and cheese (0·14). INTERPRETATION: Our estimates of ASF consumption identify populations with both lower and higher than optimal intakes. These estimates can inform the targeting of intervention, surveillance, and policy priorities relevant to both human and planetary health. FUNDING: Bill & Melinda Gates Foundation and American Heart Association.

Evaluation of the Quality of Evidence of the Association of Foods and Nutrients With Cardiovascular Disease and Diabetes: A Systematic Review.

Importance: Poor diet is a leading global factor associated with cardiometabolic disease (CMD). Understanding the quality of evidence of the associations between specific dietary factors and CMD, including effect size (relative risk [RR]) and uncertainty, is essential to guide policy and consumer actions to achieve healthy diet and public health goals. Objective: To assess the quality of evidence of the associations between specific dietary factors and CMD as well as the quantitative evidence for RRs and the uncertainty of these risk estimates. Evidence Review: PubMed and the reference lists of eligible articles were searched between May 1, 2015, and February 26, 2021, for systematic reviews with meta-analyses of randomized clinical trials and prospective cohort studies that analyzed the consumption of 1 or more of the dietary factors of interest; reported dose-response meta-analyses; included healthy adults; and assessed 1 or more of the outcomes of interest. Study characteristics and RR estimates were extracted in duplicate. For identified associations, quality of evidence was assessed using the Bradford-Hill criteria for causation. Findings: A total of 2058 potentially relevant reports were identified, from which 285 full-text articles were assessed for eligibility. The final selection of articles included 28 meta-analyses representing 62 associations between diet and CMD. Among these associations, 10 foods, 3 beverages, and 12 nutrients had at least probable evidence of associations with coronary heart disease, stroke, and/or diabetes. Most RRs ranged from 0.87 to 0.96 per daily serving change for protective associations and from 1.06 to 1.15 per daily serving change for harmful associations. Most identified associations were protective (n = 38) and a smaller number were harmful (n = 24), with a higher risk associated with higher intake. Conclusions and Relevance: This systematic review summarized the current quality of evidence of the associations of specific dietary factors with coronary heart disease, stroke, and diabetes. These findings may inform dietary guidance, the assessment of disease burden in specific populations, policy setting, and future research.

Trans Fatty Acid Biomarkers and Incident Type 2 Diabetes: Pooled Analysis of 12 Prospective Cohort Studies in the Fatty Acids and Outcomes Research Consortium (FORCE).

OBJECTIVE: Trans fatty acids (TFAs) have harmful biologic effects that could increase the risk of type 2 diabetes (T2D), but evidence remains uncertain. We aimed to investigate the prospective associations of TFA biomarkers and T2D by conducting an individual participant-level pooled analysis. RESEARCH DESIGN AND METHODS: We included data from an international consortium of 12 prospective cohorts and nested case-control studies from six nations. TFA biomarkers were measured in blood collected between 1990 and 2008 from 25,126 participants aged ≥18 years without prevalent diabetes. Each cohort conducted de novo harmonized analyses using a prespecified protocol, and findings were pooled using inverse-variance weighted meta-analysis. Heterogeneity was explored by prespecified between-study and within-study characteristics. RESULTS: During a mean follow-up of 13.5 years, 2,843 cases of incident T2D were identified. In multivariable-adjusted pooled analyses, no significant associations with T2D were identified for trans/trans-18:2, relative risk (RR) 1.09 (95% CI 0.94-1.25); cis/trans-18:2, 0.89 (0.73-1.07); and trans/cis-18:2, 0.87 (0.73-1.03). Trans-16:1n-9, total trans-18:1, and total trans-18:2 were inversely associated with T2D (RR 0.81 [95% CI 0.67-0.99], 0.86 [0.75-0.99], and 0.84 [0.74-0.96], respectively). Findings were not significantly different according to prespecified sources of potential heterogeneity (each P ≥ 0.1). CONCLUSIONS: Circulating individual trans-18:2 TFA biomarkers were not associated with risk of T2D, while trans-16:1n-9, total trans-18:1, and total trans-18:2 were inversely associated. Findings may reflect the influence of mixed TFA sources (industrial vs. natural ruminant), a general decline in TFA exposure due to policy changes during this period, or the relatively limited range of TFA levels.

Estimated Reductions in Added Sugar Intake among US Children and Youth in Response to Sugar Reduction Targets.

BACKGROUND: In 2021, the National Salt and Sugar Reduction Initiative (NSSRI) released voluntary sugar reduction targets for packaged foods and drinks in the United States. OBJECTIVE: The objectives of this study were to describe trends in added sugar intake from NSSRI foods and beverages among children and youth and estimate possible reductions if industry were to meet the targets. DESIGN: This study consisted of cross-sectional and trend analyses of demographic and 24-hour dietary recall data from eight survey cycles (2003-2004 to 2017-2018) of the National Health and Nutrition Examination Survey. PARTICIPANTS/SETTING: The study sample included 23,248 children and youth (aged 2 to 19 years). MAIN OUTCOME MEASURES: The main outcome measure was the percent of daily calories from added sugar for foods and beverages in NSSRI categories. STATISTICAL ANALYSES PERFORMED: Foods and beverages reported by participants were mapped to one of the NSSRI's categories or coded as a non-NSSRI item. Trends over time in added sugar intake were assessed using regression models. To assess possible reductions in added sugar intake if industry were to meet the targets, sales-weighted mean percent reductions for 2023 and 2026 targets were applied to NSSRI items in the 2017-2018 National Health and Nutrition Examination Suvey data. Results were examined overall and by demographic characteristics. RESULTS: From 2003-2004 to 2017-2018, added sugar intake from NSSRI foods and beverages declined, but consumption remained high. During 2017-2018, NSSRI categories accounted for 70% of US child and youth added sugar intake. If industry met the NSSRI targets, US children and youth would consume 7% (2023 targets) to 21% (2026 targets) less added sugar. CONCLUSIONS: Although added sugar intake from NSSRI foods and drinks has declined over the past decade, added sugar intake from all sources remains high and consumption of added sugar from certain NSSRI categories has remained steady over time. If met, the NSSRI targets are expected to result in meaningful reductions in added sugar intake for US children and youth.

Consumption of Ultraprocessed Foods and Diet Quality Among U.S. Children and Adults.

INTRODUCTION: Consumption of ultraprocessed foods has been linked with higher intake of added sugars, sodium, and unhealthful fats, but the associations of ultraprocessed foods with overall diet quality and major food groups are not well known. METHODS: Data were derived from the National Health and Nutrition Examination Survey (2015-2018), including 9,758 adults (aged ≥20 years) and 5,280 children (aged 2-19 years) with 24-hour dietary recalls (≥1), with analysis performed in 2020. Ultraprocessed foods were identified using the NOVA classification, with intake (% energy) assessed in quintiles. Diet quality was assessed using the validated American Heart Association 2020 continuous primary and secondary diet scores and Healthy Eating Index 2015. Poor diet was defined as <40% adherence to the American Heart Association secondary score. Generalized linear regressions estimated relationships between ultraprocessed food intake and diet quality. RESULTS: Compared with the lowest quintile of ultraprocessed food consumption (<39.1% energy), the American Heart Association primary score in adults was progressively lower in Quintile 2 (-1.99, 95% CI= -2.73, -1.25), Quintile 3 (-3.60, 95% CI= -4.47, -2.72), Quintile 4 (-5.29, 95% CI= -6.28, -4.30), and Quintile 5 (-7.24, 95% CI= -8.13, -6.36; >70.7% energy). Corresponding values in children were -2.05 (95% CI= -3.01, -1.09), -2.97 (95% CI= -4.16, -1.79), -3.82 (95% CI= -5.20, -2.44), and -6.22 (95% CI= -7.20, -5.25; >79.0% energy). The estimated proportion of children having poor diet progressively increased from 31.3% (95% CI=26.2%, 36.5%) in Quintile 1 up to 71.6% (95% CI=68.1%, 75.1%) in Quintile 5. Corresponding proportions of adults having poor diet increased from 18.1% (95% CI=14.3%, 22.0%) in Quintile 1 up to 59.7% (95% CI=55.3%, 64.1%) in Quintile 5. Findings were similar using the American Heart Association secondary score and Healthy Eating Index 2015 score. CONCLUSIONS: Higher ultraprocessed food consumption is associated with substantially lower diet quality among children and adults.

Health Impact and Cost-Effectiveness of Achieving the National Salt and Sugar Reduction Initiative Voluntary Sugar Reduction Targets in the United States: A Microsimulation Study.

BACKGROUND: High intake of added sugar is linked to weight gain and cardiometabolic risk. In 2018, the US National Salt and Sugar Reduction Initiative proposed government-supported voluntary national sugar reduction targets. This intervention's potential effects and cost-effectiveness are unclear. METHODS: A validated microsimulation model, CVD-PREDICT (Cardiovascular Disease Policy Model for Risk, Events, Detection, Interventions, Costs, and Trends), coded in C++, was used to estimate incremental changes in type 2 diabetes, cardiovascular disease (CVD), quality-adjusted life-years (QALYs), costs, and cost-effectiveness of the US National Salt and Sugar Reduction Initiative policy. The model was run at the individual level, incorporating the annual probability of each person's transition between health statuses on the basis of risk factors. The model incorporated national demographic and dietary data from the National Health and Nutrition Examination Survey across 3 cycles (2011 through 2016), added sugar-related diseases from meta-analyses, and policy costs and health-related costs from established sources. A simulated nationally representative US population was created and followed until age 100 years or death, with 2019 as the year of intervention start. Findings were evaluated over 10 years and a lifetime from health care and societal perspectives. Uncertainty was evaluated in a 1-way analysis by assuming 50% industry compliance and probabilistic sensitivity analyses through a second-order Monte Carlo approach. Model outputs included averted diabetes cases, CVD events and CVD deaths, QALYs gained, and formal health care cost savings, stratified by age, race, income, and education. RESULTS: Achieving the US National Salt and Sugar Reduction Initiative sugar reduction targets could prevent 2.48 million CVD events, 0.49 million CVD deaths, and 0.75 million diabetes cases; gain 6.67 million QALYs; and save $160.88 billion net costs from a societal perspective over a lifetime. The policy became cost-effective (<150 000/QALYs) at 6 years, highly cost-effective (<50 000/QALYs) at 7 years, and cost-saving at 9 years. Results were robust from a health care perspective, with lower (50%) industry compliance, and in probabilistic sensitivity analyses. The policy could also reduce disparities, with greatest estimated health gains per million adults among Black or Hispanic individuals, lower income, and less educated Americans. CONCLUSIONS: Implementing and achieving the US National Salt and Sugar Reduction Initiative sugar reformation targets could generate substantial health gains, equity gains, and cost savings.

Dietary Sugar Intake and Its Association with Obesity in Children and Adolescents.

Sugar intake has been associated with increased prevalence of childhood overweight/obesity; however, results remain controversial. The aim of this study was to examine the probability of overweight/obesity with higher sugar intakes, accounting for other dietary intakes. Data from 1165 children and adolescents aged ≥2-18 years (66.8% males) enrolled in the Hellenic National Nutrition and Health Survey (HNNHS) were used; specifically, 781 children aged 2-11 years and 384 adolescents 12-18 years. Total and added sugar intake were assessed using two 24 h recalls (24 hR). Foods were categorized into specific food groups to evaluate the main foods contributing to intakes. A significant proportion of children (18.7%) and adolescents (24.5%) exceeded the recommended cut-off of 10% of total energy intake from added sugars. Sweets (29.8%) and processed/refined grains and cereals (19.1%) were the main sources of added sugars in both age groups, while in adolescents, the third main contributor was sugar-sweetened beverages (20.6%). Being overweight or obese was 2.57 (p = 0.002) and 1.77 (p = 0.047) times more likely for intakes ≥10% of total energy from added sugars compared to less <10%, when accounting for food groups and macronutrient intakes, respectively. The predicted probability of becoming obese was also significant with higher total and added-sugar consumption. We conclude that high consumption of added sugars increased the probability for overweight/obesity among youth, irrespectively of other dietary or macronutrient intakes.

Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.

BACKGROUND: The workplace offers a unique opportunity for effective health promotion. We aimed to comprehensively study the effectiveness of multicomponent worksite wellness programmes for improving diet and cardiometabolic risk factors. METHODS: We did a systematic literature review and meta-analysis, following PRISMA guidelines. We searched PubMed-MEDLINE, Embase, the Cochrane Library, Web of Science, and Education Resources Information Center, from Jan 1, 1990, to June 30, 2020, for studies with controlled evaluation designs that assessed multicomponent workplace wellness programmes. Investigators independently appraised the evidence and extracted the data. Outcomes were dietary factors, anthropometric measures, and cardiometabolic risk factors. Pooled effects were calculated by inverse-variance random-effects meta-analysis. Potential sources of heterogeneity and study biases were evaluated. FINDINGS: From 10 169 abstracts reviewed, 121 studies (82 [68%] randomised controlled trials and 39 [32%] quasi-experimental interventions) met the eligibility criteria. Most studies were done in North America (57 [47%]), and Europe, Australia, or New Zealand (36 [30%]). The median number of participants was 413·0 (IQR 124·0-904·0), and median duration of intervention was 9·0 months (4·5-18·0). Workplace wellness programmes improved fruit and vegetable consumption (0·27 servings per day [95% CI 0·16 to 0·37]), fruit consumption (0·20 servings per day [0·11 to 0·28]), body-mass index (-0·22 kg/m2 [-0·28 to -0·17]), waist circumference (-1·47 cm [-1·96 to -0·98]), systolic blood pressure (-2·03 mm Hg [-3·16 to -0·89]), and LDL cholesterol (-5·18 mg/dL [-7·83 to -2·53]), and to a lesser extent improved total fat intake (-1·18% of daily energy intake [-1·78 to -0·58]), saturated fat intake (-0·70% of daily energy [-1·22 to -0·18]), bodyweight (-0·92 kg [-1·11 to -0·72]), diastolic blood pressure (-1·11 mm Hg [-1·78 to -0·44]), fasting blood glucose (-1·81 mg/dL [-3·33 to -0·28]), HDL cholesterol (1·11 mg/dL [0·48 to 1·74]), and triglycerides (-5·38 mg/dL [-9·18 to -1·59]). No significant benefits were observed for intake of vegetables (0·03 servings per day [95% CI -0·04 to 0·10]), fibre (0·26 g per day [-0·15 to 0·67]), polyunsaturated fat (-0·23% of daily energy [-0·59 to 0·13]), or for body fat (-0·80% [-1·80 to 0·21]), waist-to-hip ratio (-0·00 ratio [-0·01 to 0·00]), or lean mass (1·01 kg [-0·82 to 2·83]). Heterogeneity values ranged from 46·9% to 91·5%. Between-study differences in outcomes were not significantly explained by study design, location, population, or similar factors in heterogeneity analyses. INTERPRETATION: Workplace wellness programmes are associated with improvements in specific dietary, anthropometric, and cardiometabolic risk indicators. The heterogeneity identified in study designs and results should be considered when using these programmes as strategies to improve cardiometabolic health. FUNDING: National Heart, Lung, and Blood Institute.

Trends in junk food consumption among US children and adults, 2001-2018.

BACKGROUND: Trends in junk food consumption, a risk for obesity, are not well established. OBJECTIVES: We examined national trends in types of junk food (excluding beverages) and their sources (grocery, restaurants, schools, etc.), overall and in population subgroups. METHODS: We assessed 29,970 children (aged 2-19 y) and 44,501 adults (aged ≥20 y) with 24-h dietary recall data from 9 NHANES cycles (2001-2002 to 2017-2018). Trends in junk food were assessed over time using 1-d values for individuals with single recalls and 2-d means for others. RESULTS: From 2001 to 2018, percent energy (%E) from junk food remained stable for children (from 18.1% to 17.5%, P-trend = 0.25) and decreased for adults (14.1% to 13.0%, P-trend = 0.002). Among children, increases occurred in %E from crackers (1.19% to 1.35%) and snack/meal bars (0.38% to 0.69%) and decreases in candy (2.58% to 1.96%) and other desserts (3.11% to 2.48%) (all P-trends < 0.01). Among adults, increases occurred in snack/meal bars (0.31% to 0.78%, P-trend < 0.001) and decreases in candy (1.97% to 1.55%; P-trend < 0.001), sweet bakery products (5.52% to 4.98%; P-trend = 0.04), and other desserts (2.19% to 1.86%; P-trend = 0.001). In 2017-2018, grocery stores provided the largest proportion of junk food (72.7% for children, 77.1% for adults), followed by other sources (13.1%, 12.1%), restaurants (8.05%, 9.11%), schools (4.86%), and worksites (1.99%). In both children and adults, junk food intake was higher among non-Hispanic white and black Americans compared with Mexican Americans, among those with higher compared with lower education, among women compared with men, and among older compared with younger adults. In sensitivity analyses using only 1-d recalls, mean junk food intake each cycle was ∼0.8-1.0 and 0.3-0.4%E units higher in children and adults, respectively, with otherwise similar trends and subgroup differences over time. CONCLUSIONS: From 2001 to 2018, %E from junk food represented nearly 1 in 5 calories among children, without change, and nearly 1 in 7 calories, with modest decrease, among adults, with disparities in subgroups.

Blood n-3 fatty acid levels and total and cause-specific mortality from 17 prospective studies.

The health effects of omega-3 fatty acids have been controversial. Here we report the results of a de novo pooled analysis conducted with data from 17 prospective cohort studies examining the associations between blood omega-3 fatty acid levels and risk for all-cause mortality. Over a median of 16 years of follow-up, 15,720 deaths occurred among 42,466 individuals. We found that, after multivariable adjustment for relevant risk factors, risk for death from all causes was significantly lower (by 15-18%, at least p < 0.003) in the highest vs the lowest quintile for circulating long chain (20-22 carbon) omega-3 fatty acids (eicosapentaenoic, docosapentaenoic, and docosahexaenoic acids). Similar relationships were seen for death from cardiovascular disease, cancer and other causes. No associations were seen with the 18-carbon omega-3, alpha-linolenic acid. These findings suggest that higher circulating levels of marine n-3 PUFA are associated with a lower risk of premature death.